The great HIV debate

There are always NHS cost 'efficiencies' which need to be made - but sometimes the short-sightedness of our Health Lords and Masters defeats me. This week, it's the turn of HIV.

I don't know if you've noticed, but the NHS costs a lot. In 2014, the NHS spent £14.4 billion on drugs, a rise of 7.6% on the previous year. Of course there are cost 'efficiencies' which need to be made - but sometimes the short-sightedness of our Health Lords and Masters defeats me.

This week, it's the turn of HIV - the short-term cost of prevention weighed up against the long-term cost of treatment. The good news is that extraordinary progress has been made in the treatment of HIV - for people diagnosed with HIV at the age of 20, life expectancy increased from 36 to 52 years over just half a decade from 2000-2 to 2006-7. Many patients with HIV live full and productive lives - but it is still an incurable, lifelong condition which needs lifelong treatment. And that's where I'm at a loss as to NHS England's logic. Because the lifetime cost of treatment for a single HIV patient is about £360,000, even before the human cost is taken into account. Anything that cuts the numbers of patients needing this treatment with multiple drugs has have a fair chance of saving our society money in the long term.

Truvada®, also known as PrEP (pre-exposure prophylaxis), cut the risk of contracting HIV by 86% in a study last year of over 500 men at high risk. Of course, 'relative risk reduction' can be misleading (buying two lottery tickets increases your likelihood of winning by 100%, but the odds are still minuscule). But to put it into perspective, within a year in this study, 19 men out of 270 became HIV- positive, compared to three in the PrEP group. Multiply that by the tens of thousands of people at high risk, and the numbers of cases prevented is eye-boggling. So is the saving in terms of the long- term cost of treating them.

But this week, NHS England announced that it would not fund PrEP. Its excuse was that if it did, it would lay itself open to legal challenge, both from manufacturers of competitor drugs, and from groups with a vested interest in other treatments the NHS might not fund if they used the money on PrEP. In a statement, they said they had 'considered and accepted NHS England's external legal advice that it does not have the legal power to commission PrEP'.

If you're getting a sense of déjà vu, that's because this isn't the first time NHS England has come to the same conclusion. After hopes raised over the last year for national funding, in March NHS England admitted that PrEP treatment 'can be highly effective in preventing HIV as long as the drugs are taken regularly', but laid responsibility for funding it firmly at the door of local authorities. As a sop, they explained that they were 'committed to working with local authorities, Public Health England, the Department of Health and other stakeholders as further consideration is given to making PrEP available for HIV prevention.' Leading sexual health charity condemnation was fast and damning, and NHS England went back to the drawing board, only to come back with the same decision three months later.

Effectively, NHS England is hiding behind its lawyers - and don't even get me started on how much they're costing the taxpayer or how many drugs you could fund with their salaries. To me, the sums are simple and the argument compelling. There's no point shouting that high-risk individuals (mostly men who have unprotected sex with men) shouldn't do it - they are doing it, and they're going to carry on doing it. From a moral perspective, if we're going to refuse them treatment, we should deny treatment to anyone who's overweight, or a smoker, or likes a glass of wine, or went on holiday to an exotic location and came back with malaria.

In the long term, the NHS will carry on picking up the tab for a lifetime of treatment once patients are diagnosed with HIV. Some of the drugs we have now may get much cheaper once they come off patent. But HIV is a virus, and viruses evolve, so we're likely to continue to need new drugs, at a cost of about £1 billion each to develop. Prevention or cure/lifetime-treatment-because-we-can't-cure-it? From where I'm sitting, there's no contest. And it's high time those expensive lawyers really earnt their money and came up with a way to fund a really effective prevention.

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